Men treated for prostate cancer did not consider urinary, bowel, or sexual dysfunction as problems of health
Q How do men who have been treated for prostate cancer perceive the side effects of urinary, bowel, and sexual dysfunction?
33 men 60–74 years of age who had been treated for prostate cancer and had experienced urinary, bowel, or sexual dysfunctions after, but not before, treatment. All men were recruited from a cohort of prostate cancer patients who had completed self report questionnaires before treatment and at 6 month, 12 month, and 5 year follow up. Questionnaires included disease specific and generic quality of life (QOL) measures. Responses indicated both high levels of dysfunction and high generic scores.
Face-to-face semistructured interviews were conducted at a mean of 5–6 years after prostate cancer treatment. Interviews were audiotaped and transcribed verbatim. To explore the discrepancy between the presence of urinary, bowel, or sexual dysfunction and high QOL scores, patients were randomly allocated to 2 interview samples: sample A interviews aimed to determine whether discrepancies could be explained by response shift (ie, participants’ adaptation to changed health), whereas sample B interviews aimed at exploring whether insensitivity of generic measures to changes in health status after prostate cancer treatment could explain the discrepancies. 2 investigators categorised the mechanism of each instance of discrepancy as a response shift or insensitivity of generic measures. After discussing and comparing the evidence, “old age” was added as a third mechanism.
Old age. Men tended to consider diminished sexual function as part of the normal ageing process. They accepted sexual dysfunction as a side effect of prostate cancer treatment but also used old age as a reason for not considering it to be a bother.
Response shift. A response shift was observed in men’s explanations of their acceptance of urinary and bowel dysfunction. Their level of acceptance with respect to these side effects changed because they felt they were problems that one got used to over the passage of time and because they were side effects of life saving prostate cancer treatment. However, one respondent who expressed initial acceptance of side effects (because he felt that cancer remission was worth it) began to be annoyed by the persisting side effects over time.
Insensitivity. Men did not include urinary, bowel, and sexual dysfunction problems in answers to general health questions on QOL measures because they did not consider these problems as aspects of health. One respondent with urinary leakage referred to it as a “small inconvenience” despite the fact that he had to use the bathroom several times each night. Another respondent declared himself healthy despite having urinary leakage and erectile dysfunction.
Men who were treated for prostate cancer did not consider the side effects of treatment (urinary, bowel, or sexual dysfunction) to be problems of health and accepted them as the inevitable side effects of life saving treatment. Sexual dysfunction was frequently associated with the normal ageing process.
- John Oliffe, RN, MEd, PhD
The study by Korfage et al provides empirical and methodological insights into participants’ perceptions of health in the context of having been treated for prostate cancer. The findings confirm that complex, diverse, and perhaps contradictory patterns exist among prostate cancer survivors in matters related to common treatment-induced side effects including erectile dysfunction, and urinary and bowel incontinence. Moreover, the authors explain that the discordant relationship between such seemingly significant morbidities and men’s high QOL ratings are likely an artefact of how men construct health and ageing, as well as the insensitivities of some generic QOL survey questionnaires.
From a methodological perspective, the fine grained analysis afforded by a qualitative approach is appropriately situated as complementary, and although not explicitly stated, the information gleaned could reliably inform future QOL survey design focused on prostate cancer survivors.
In my opinion, the importance and implications of the study findings are somewhat understated in the original article. From a clinical perspective, the findings offer practitioners valuable understanding about how some older men rationalise their illness and perhaps downplay morbidities, while defining health using biological or functional ideals about what aged bodies can realistically expect to achieve. This is particularly important information for clinicians who hope to thoughtfully promote the health of prostate cancer survivors. In terms of future studies, one central research question, at least for me, was informed by the findings: what constitutes health in the lives of prostate cancer survivors? This seems to be an important follow up because, in a field dominated by performance models (mental, physical, and sexual) of men’s health, there is little understanding of “what health is” among older men generally and among prostate cancer survivors in particular.
For correspondence: Dr I J Korfage, Department of Public Health, ErasmusMC, University Medical Center Rotterdam, Rotterdam, The Netherlands.
Source of funding: Dutch Cancer Society.